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EARLY CHILDHOOD INTERVENTION AUSTRALIA
7th National Conference Adelaide, 5th-7th March 2006
INVITED ADDRESS
Parallel processes:
Common features of effective parenting, human services,
management and government
Tim Moore
Senior Research Fellow, Centre for Community Child Health,
Murdoch Children’s Research Institute, Royal Children’s
Hospital, Melbourne
This paper proposes that there are features that are common to
effective relationships between parents / caregivers and young
children, human service providers and parents, managers and staff,
services and communities, and governments and services. These form
a cascade of parallel processes. These commonalities can be seen
when one looks at the key features of effective parenting /
caregiving of infants, interventions with children with
disabilities, family-centred practice, core helping and counselling
skills, staff management and supervision, and community-centred
practice. The common features to all forms of effective
relationships include attunement / engagement, contingent
responding, emotional communication, empowerment and
strength-building, managing communication breakdowns, moderate
stress / challenges, and building coherent narratives. The paper
describes what is known about the neurological bases for these
parallel processes. These include the way young children’s brains
are programmed through relationships with parents and caregivers,
and the key role that mirror neurons play. Later development
continues to be intimately shaped by the nature of ongoing
relationships, and therefore there is some scope for
neurobiological / behavioural ‘reprogramming’ - early adverse
experiences can be offset partially or wholly through subsequent
positive relationships, including relationships with professionals.
Finally, the implications of these findings for early childhood
intervention practice and services are explored. Understanding the
key features of effective relationships will obviously help
practitioners in their work with young children with disabilities,
but also highlights the nature and importance of the relationships
they build with parents. The principle of parallel process also has
profound implications for managers and policy makers.
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‘You need to have an experience with someone first - then you
can reproduce it.’
Gerhardt (2004) INTRODUCTION
Rob Gibson, the former viticulturalist in charge of the
Penfold's Grange vineyards, has developed a detailed knowledge of a
vine’s water requirements.* Gibson has found that in order to
produce exceptional grapes, it is necessary to keep vines in
tension but not stress. Unfortunately, he says, vines are complex
living organisms with deep root systems, subject to many variables
which may compromise this 'balance'. During a vine’s growing
season, water is removed from the root zone to the vines canopy
until the moisture content drops to a level which causes the vine
to wilt. If the water is not replaced in the root zone, the vine
will degenerate. In order to prevent the vine from wilting, there
should remain an adequate amount of water in the soil for the vine
to survive, topped up by rainfall. When the opposite happens, and
the pore spaces of the soil particles are totally filled with
water, the soil becomes saturated. If this goes on for too long,
the vine’s roots become water-logged and the vine may even die.
Soil texture is another important element in the soil’s capacity
for retaining water and determining the vine’s permanent wilting
threshold (ie. state of tension). The more open the soil, the less
capacity to withhold water and the deeper the roots must go in
order to achieve a balanced moisture position. Vines grow best in
areas with scant summer rain, relying on water stored in the soil.
If sufficient soil moisture is absent, then some form of irrigation
must take place. Not irrigating the vine does not necessarily
produce superior grapes, but may result instead in ‘stressed’
wines. Gibson’s point is that the viticulturalist must keep a
constant eye on the state of the vines, taking account to their
changing needs over the course of the growing season, and aiming to
keep them in a state of tension rather than stress. As I aim to
show in this paper, these key features of viticulture have
intriguing correspondences with the key features of human
relationships. Outline of paper The paper covers the following
topics. • The importance of relationships – what evidence there is
that relationships of different
kinds make a difference to our development and functioning, and
what we know about how they make a difference
• Common features of effective relationships – what
characteristics of relationships
appear to be common to all types of relationships • The
neurobiology of interpersonal relationships – what we know about
how
relationships affect the development and functioning of the
brain • Parallel process and the cascade of parallel processes –
how relationships affect
other relationships, and how relationships can be seen as
forming a cascade from government / societal levels through to
parent and child
• Implications for services and service systems –
relationship-based practice as core
feature of effective services and service systems
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• Conclusions – eight summary points Finally, I will return to
Rob Gibson’s principles of effective viticulture to see what
correspondences there are with the world of human services. THE
IMPORTANCE OF RELATIONSHIPS In this section, we will examine the
relationships between parents and children, caregivers and
children, parents and caregivers of children with disabilities,
professionals and parents, doctors and patients, psychotherapists
and clients, managers and staff, trainers and trainees, services
and communities, and governments and communities. Two aspects of
each of these relationships will be explored: first, the evidence
that the relationship in question has a significant impact on the
development and well-being of those involved, and second, what
features of the relationship are known to be associated with
positive outcomes for those in the relationship. Parent / child
relationships Of all the relationships to be considered, the
importance of that between parents and their young children is the
one for which we have most evidence. This evidence shows that young
children develop through their relationships with the important
people in their lives (Bronfenbrenner, 1988; Gerhardt, 2004;
National Scientific Council on the Developing Child, 2004; Richter,
2004). These relationships are what Shonkoff and colleagues
(National Scientific Council on the Developing Child, 2004) call
the ‘active ingredients’ of the environment’s influence on healthy
human development.
‘The essential features of the environment that influence
children’s development are their relationships with the important
people in their lives – beginning with their parents and other
family members, and extending outward to include child care
providers, teachers, and coaches – within the places to which they
are exposed – from playgrounds to libraries to schools to soccer
leagues.’ (p. 4).
In a similar vein, Bronbrenner (1988) has said:
‘In order to develop normally, a child needs the enduring,
irrational involvement of one or more adults in care of and in
joint activity with that child. In short, somebody’s got to be
crazy about that kid. Someone also has to be there, and to be doing
something – not alone but together with the child.’
On the basis of a review of current theory and empirical
evidence on the importance of caregiver-child relationships for the
survival and healthy development of children, Richter (2004)
concludes that infants and caregivers are prepared, by evolutionary
adaptation, for caring interactions through which the child's
potential human capacities are realized. Furthermore, these
nurturant caregiver-child relationships have universal features
across cultures, regardless of differences in specific child care
practices. The inescapable conclusion is that children’s
development is shaped, for better or worst, by their closest
relationships. The next question to consider is what we know about
the key features of the parent-child relationship that contribute
to young children’s positive development.
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Features of effective parenting There are numerous accounts of
the key features of positive parenting, including Brazelton and
Greenspan (2000), Bronfenbrenner (1990), Gerhardt (2004), Greenspan
and Lewis (1999), National Scientific Council on the Developing
Child (2004), Ramey and Ramey (1992, 1999), Shonkoff and Phillips
(2000) and Siegel (2001). According to Shonkoff and colleagues
(National Scientific Council on the Developing Child, 2004), the
features of those relationships that most promote positive
development and well-being are individualized responsiveness,
mutual action-and-interaction, and an emotional connection to
another human being. Bronfenbrenner (1990) proposed that the core
process involved in promoting child development is the child's
emotional, physical, intellectual and social need for ongoing,
mutual interaction with a caring adult or adults:
‘In order to develop - intellectually, emotionally, socially,
and morally - a child requires participation in progressively more
complex reciprocal activity, on a regular basis over an extended
period in the child's life, with one or more persons with whom the
child develops a strong, mutual, irrational, emotional attachment
and who is committed to the child's well-being and development,
preferably for life.’ (Bronfenbrenner, 1990)
Siegel (2001) has focused on attachment, and identified the five
basic elements of how caregivers can foster a secure attachment in
the children under their care:
• Collaboration - secure relationships are based on
collaborative, contingent communication.
• Reflective dialogue - secure attachment relationships involve
the verbal sharing of a focus on the internal experience of each
member of the pair.
• Repair - when attuned communication is disrupted, as it
inevitably will be, repair of the rupture is an important part of
re-establishing the connection between the parent and child.
• Coherent narratives - the connection of the past, present, and
future is one of the central processes of the mind in the creation
of the autobiographical form of self-awareness.
• Emotional communication - attachment figures can amplify and
share in the positive, joyful experiences, as well as remain
connected to the child during moments of uncomfortable emotion.
A synthesis of these and other recent attempts to identify the
key experiences that young children need to promote their general
development (Brazelton and Greenspan, 2000; Gerhardt, 2004;
Greenspan and Lewis, 1999; Guralnick, 1997, 1998; National
Scientific Council on the Developing Child, 2004; Ramey and Ramey,
1992, 1999: Richter, 2004; Shonkoff and Phillips, 2000; Siegel,
2001) suggests that we can best promote children’s development by
providing them with
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close and ongoing caring relationships with parents or
caregivers
adults who recognise and are responsive to the particular
child’s needs, feelings and interests
adults who are able to help children understand and regulate
their emotions
adults who are able to help children understand their own mental
states and those of others
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adults who are able to help children negotiate temporary
breakdowns and ruptures in relationships
protection from harms that children fear and from threats of
which they may be unaware
clear behavioural limits and expectations that are consistently
and benignly maintained
opportunities and support for children to learn new skills and
capabilities that are within their reach
opportunities for children to develop social skills through
regular contact with a range of adults and other children
opportunities and support for children to learn how to resolve
conflict with others cooperatively
stable and supportive communities that are accepting of a
different families and cultures Parenting that provides a basic
level of each of these experiences is sufficient to trigger
children’s biological capacities to become competent and healthy
members of families and communities. Parents do not have to be
perfect at this job: indeed, as Hoghughi and Speight (1998) point
out,
‘ …. it is unhelpful and unrealistic to demand perfection of
parents, and to do so undermines the efforts of the vast majority
of parents who are in all practical respects ‘good enough’ to meet
their children's needs.(p. 293)
What is needed is what Winnicott (1965) called ‘good enough
parenting’. Having established the importance of early
relationships for development and the key features of positive
parenting, we turn next to a consideration of the relationship
between non-parental caregivers and young children. Caregiver /
child relationships What do we know about the effect of caregiver-
child relationships on child development and well-being? There is
strong evidence that the quality of child care is a significant
factor in shaping children’s development (Clarke-Stewart and
Allhusen, 2005; National Scientific Council on the Developing
Child, 2004, 2005; Shonkoff and Phillips, 2000):
‘While child care of poor quality is associated with poorer
developmental outcomes, high-quality care is associated with
outcomes that all parents want to see in their children, ranging
from cooperation with adults to the ability to initiate and sustain
positive exchanges with peers, to early competence in math and
reading.’ (Shonkoff and Phillips, 2000, pp. 313-4)
Not surprisingly, the qualities of non-parental caregiving
relationships that best promote children’s well-being and
development match those that characterise positive parent-child
relationships. According to the Committee on Integrating the
Science of Early Childhood Development (Shonkoff and Phillips,
2000), quality of care ultimately boils down to the quality of the
relationship between the child care provider and the child:
‘Young children whose caregivers provide ample verbal and
cognitive stimulation, who are sensitive and responsive, and who
give them generous amounts of attention and support are more
advanced in all realms of development compared with children who
fail to receive these important inputs.’ (p. 315).
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This conclusion applies to infants, toddlers and preschoolers
and also applies to all forms of child care, ranging from relatives
to centre-based programs. Continuity of care is also important -
more stable providers have been found to engage in more appropriate
attentive and engaged interactions with the children in their care.
Lally (2000) has identified seven essential supports that very
young children need at home and in child care:
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Nurturance involves providing warmth, feeding, and protection,
and responding to each baby individually, thereby promoting strong
attachment.
Support involves helping children master key early developmental
challenges by acknowledging their powerful feelings, encouraging
curiosity and independence, and, at the same time, teaching and
enforcing the rules that allow children and adults to live in
harmony.
Security involves providing an environment in which the child
feels safe.
Predictability involves rituals and rhythms throughout the day
that follow regular sequences, and is both social (people I know
will be there for me) and spatial (I know where to find the puzzles
and where I can ride the tricycle).
Focus involves the caregiver paying attention to what fascinates
each child, protecting the child from too much stimulation, and
providing a calm and reliable presence that frees the child’s
energy for learning.
Encouragement involves caregivers understanding that children
learn a great deal through their own interest and initiation, and
responding with legitimate, specific enthusiasm rather than general
cheerleading or coaching.
Expansion of the young child’s learning involves building the
child’s language by carefully observing the child’s cues and
interests, commenting on what the child is doing, and encouraging
the child to use words to guide himself through activities.
Lally (2000) suggests that nurturance, support, security, and
predictability let children know that they can count on being loved
and cared for in the child care setting. Predictability, focus,
encouragement and expansion facilitate the young child’s
intellectual development. These and other findings (Lloyd-Jones,
2002; Melhuish, 2003) testify to the important effects that
non-parental care can have on children’s development, and the
features of such care that promote positive development in young
children. These features are essentially the same as those that
characterise effective parent-child relationships. The next set of
relationships to be considered are those between parents /
caregivers and children with developmental delays and disabilities.
Parenting / caregiving for children with developmental delays and
disabilities Does the quality of parenting and caregiving matter
just as much as for children with developmental delays and
disabilities as it does for children without developmental
problems? Since the core needs of such children are the same as
those who do not have developmental problems, the answer is likely
to be yes. Moore (2001) has argued that there is evidence of an
increasing convergence toward what Lieber, Schwatrz, Sandall, Horn
and Wolery (1999) have called ‘a compatible philosophy of
instruction’ between the early childhood and early childhood
intervention fields. This evidence comes from studies of
naturalistic approaches to teaching (eg. Delprato, 2001; Kaiser and
Hester, 1996), effective ways of working with multiply disabled
children (eg. Klein,
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Chen and Haney, 2000), parent-child and teacher-child
interactions (eg. Mahoney, Boyce, Fewell, Spiker and Wheeden,
1998), and longitudinal studies of preschool curricula for at-risk
children (eg. Marcon, 1999). There are many examples of this form
of convergence, but one example will have to suffice for the
present. In a recent curriculum devised specifically for young
children who have multiple disabilities (Klein, Chen and Haney,
2000), caregivers and service providers facilitate the child’s
learning by
• carefully and systematically observing the child
• providing predictable routines
• establishing accurate interpretations and providing contingent
responses to the child’s cues
• building on the child’s preferences and interests to motivate
communication
• providing enough time for the child to respond
• making input meaningful through consistent, appropriately
paced experience What is striking about these strategies is that
they are immediately recognisable as those that characterise
sensitive teaching of any child. The only difference in their
application is that children with multiple disabilities are likely
to learn little or nothing unless all these strategies are properly
deployed, whereas children without disabilities are able to learn
something even when the teaching is less than ideal. However, they
will learn most effectively when taught according to the above
principles which apply equally to both groups. On the basis of this
and other examples, Moore (2001) argued that the most effective
ways of promoting self-sustaining learning strategies in young
children - with or without developmental disabilities - are
• to provide them with as many naturally occurring learning
opportunities as possible
• to pay constant attention to whatever they are paying
attention to and are interested in
• to join with them in some sort of communication or interaction
about this, and
• to trust their capacity to learn In short, we should be
seeking to empower children (Moore, 2000). These strategies are, in
fact, developmentally appropriate practices that one would use with
every child, and which, with various adaptations, are appropriate
for children with disabilities as well. Establishing the importance
and nature of positive parent-child and caregiver-child
relationships is relatively easy. What about the relationship
between professionals and parents? Professional / parent
relationships Within the early childhood intervention field, the
importance of the relationship between the workers and the parents
has long been recognised (Dunst, Trivette and Deal, 1988; Dunst and
Trivette, 1996; Hornby, 1994; Kalmanson and Seligman, 1992). As
Hornby (1994) put it,
‘The competence of professionals in working with parents is as
important as expertise in their own professional areas in
determining the effectiveness of their work with children with
disabilities.’
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Kalmanson and Seligman (1992) argued that this was the case even
when the relationship itself is not the focus of the
intervention:
‘Effective and sympathetic working relationships enhance
parents’ all too often neglected recognition that is their efforts
that are ultimately most important to their infants. Families with
special needs often feel that their particular difficulties set
them apart from others, and a good relationship with a professional
can enhance the sense of being understood and supported. This, in
turn, can lead to changes in the parent-child relationship.’
The importance of collaborative parent-professional
relationships is central to family-centred practice, the key
philosophy underpinning early childhood intervention service
delivery (Moore and Larkin, 2006; Turnbull, Turbiville and
Turnbull, 2000; Turnbull and Turnbull, 2000). On the basis of a
review of the literature on family-centred practice, Moore and
Larkin (2006) identify the key family-centred practices, including
the following:
• Families and family members are treated with dignity and
respect at all times
• Services are sensitive and responsive to family cultural,
ethnic, and socio-economic diversity
• Services are based on the needs and priorities of families
• Services are provided in a flexible fashion according to the
evolving needs and circumstances of particular families.
• Service providers acknowledge and respect the family’s expert
knowledge of the child and the family circumstances as
complementing their own professional expertise
• Parents are given opportunities to participate fully in the
planning and delivery of services, and service providers support
and respect the choices they make.
The implication of these different accounts of
parent-professional relationships is that how early childhood
intervention services are delivered is as important as what is
delivered (Dunst, Trivette and Deal, 1988; Pawl and St. John,
1998). What do we know about the key features of effective
professional-parent relationships skills? There are numerous
accounts of what skills are involved (eg. Davis, Day and Bidmead,
2002; Gilkerson and Ritzler, 2005; Moore and Moore, 2003).
According to Moore and Moore (2003), the key skills involved in
effective help-giving are
• skills to start people talking (observation of people’s
behaviour and mood, door openers),
• skills to keep people talking (non-verbal attending, minimal
encouragers, reflective listening, available attitude),
• skills to understand what people are saying and feeling
(observing, reflecting feelings, questioning and clarifying,
repeating and rephrasing, paraphrasing and summarizing), and
• skills to help people move forward (questioning, summarising,
assertiveness and challenging, clarifying goals, problem
solving).
Gilkerson and Ritzler (2005) propose that the core practice
skills needed for effective work with families and others include
the capacity to listen carefully, demonstrate concern and empathy,
promote reflection, observe and highlight the parent/child
relationship, respect role boundaries, respond thoughtfully in
emotionally intense interactions, and understand, regulate, and use
one’s own feelings. Similarly, Davis, Day and Bidmead (2002)
identify the core communication skills of helpers as attention /
active listening, prompting and
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exploration, empathic responding, summarizing, enabling change,
negotiating, and problem solving. There are many direct
correspondences between these different accounts. One of the less
obvious but nevertheless important elements of effective helping is
being able to challenge the person being helped when necessary.
According to Heron (1990), confronting others can cause anxiety in
the confronter. This anxiety can distort behaviour in two ways,
leading either to ‘pussyfooting’ or ‘clobbering’, neither of which
enable the person being challenged to hear the message. In a
similar vein, Furlong (2001) talks about the potential conflict
between ‘colluding’ and ‘colliding’, that is, between either
accepting the world view of clients too easily, or confronting them
too fiercely. Effective help-giving involves striking a balance
between these extremes and, when appropriate, challenging the
client in ways that promote growth. Another analysis of the key
features of effective help-giving comes from Dunst and Trivette
(1996). On the basis of a number of studies they have conducted on
the characteristics and effects of help-giving behaviours, they
conclude that there are three elements of effective help-giving: •
Technical knowledge and skills. This refers to the help-giver’s
specialist knowledge
and skills. High quality technical knowledge and skills result
in the implementation of appropriate educational, therapeutic and
medical interventions. Help which is technically of a high quality
but which does not incorporate the other two elements can have
positive outcomes in one area (eg. in the child’s health) but
negative outcomes in others (eg. parental resentment and
disempowerment as a result of the manner in which the services are
delivered).
• Help-giver behaviours and attributions. Help-giver behaviours
which positively influence psychological well-being include good
listening, empathy and warmth. Help-giver attributions that have
positive outcomes include beliefs in the person or family’s
competences and capabilities. Positive help-giver behaviours and
attributions result in (a) greater parental satisfaction with and
acceptance of helping, and (b) greater psychological and emotional
well-being. Help-giving behaviours and attributions are a necessary
but not sufficient condition for strengthening family competencies
and developing new capabilities. To achieve that, the third element
of effective help-giving is necessary.
• Participatory involvement. This entails the recipients of help
being offered information
about intervention options, sharing decision making, and being
directly involved in acting on decisions. Effective participatory
involvement results in (a) parents feeling more in control, and (b)
strengthening of parental competencies.
All three elements need to be present for help-giving to be
truly effective. Thus, there is evidence that family-centred
programs models incorporating participatory help-giving practices
are more effective in empowering families (ie. in supporting and
strengthening family competencies and problem solving
abilities)(Judge, 1997; King, King, Rosenbaum and Goffin, 1999;
Thompson, Lobb, Elling, Herman, Jurkiewicz and Hulleza, 1997;
Trivette, Dunst and Hamby, 1996a, 1996b). Another way of
understanding professional-parent relationships is in terms of the
key qualities needed by professionals to relate well to parents
(Blue-Banning, Summers, Frankland, Nelson and Beegle, 2004; Davis,
Day and Bidmead (2002). According to Hilton Davis and colleagues
(Davis, Day and Bidmead, 2002), the following qualities are needed
for effective helping:
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Respect. This is the foremost attitude, and refers to the helper
trying to suspend judgemental thinking; valuing parents as
individuals; thinking positively about them without imposing
conditions, and regardless of their problems, status, nationality,
values all other personal characteristics.
Genuineness. This involves being open to experience, perceiving
it accurately, and not distorting it with defences, personal
prejudices and one's own problems. People who are genuine are not
acting a part or pretending, deliberately or otherwise. They are
real in appearing to be what they are, and are flexible and
prepared to change.
Humility. This is closely related to both respect and
genuineness. It involves the helper not having an inflated sense of
his/her own importance in relation to parents.
Empathy. This refers to a general attempt by the helper to
understand the world from the viewpoint of the parents. What is
particularly important is that helpers demonstrate their
understanding to parents.
Personal integrity. This refers to the capacity of the helper to
be strong enough to support those who are vulnerable, to tolerate
the anxieties of the helping situation, and take a reasonably
independent viewpoint.
Quiet enthusiasm. This involves taking pride in what one does
and enjoying that the attempt to do it well for the benefit of
parents.
Similar qualities appear in the list of indicators of
professional behaviour that Blue-Banning, Summers, Frankland,
Nelson and Beegle (2004) have identified as facilitating
collaborative partnerships with parents:
• Communication: The quality of communication is positive,
understandable, and respectful among all members at all levels of
the partnership. The quantity of communication is also at a level
to enable efficient and effective coordination and understanding
among all members.
• Commitment: The members of the partnership share a sense of
assurance about (a) each other's devotion and loyalty to the child
and family, and (b) each other's belief in the importance of the
goals being pursued on behalf of the child and family.
• Equality: The members of the partnership feel a sense of
equity in decision making and service implementation, and actively
work to ensure that all other members of the partnership feel
equally powerful in their ability to influence outcomes for
children and families
• Skills: Members of the partnership perceive that others on the
team demonstrate competence, including service providers' ability
to fulfill their roles and to demonstrate recommended practice
approaches to working with children and families.
• Trust: The members of the partnership share a sense of
assurance about the reliability or dependability of the character,
ability, strength, or truth of the other members of the
partnership.
• Respect: The members of the partnership regard each other with
esteem and demonstrate that esteem and through actions
communications.
To sum up, we have seen that how early childhood intervention
services are delivered is as important as what is delivered; that
is, the nature and quality of the relationships between parents and
professionals make a significant difference to the effectiveness of
the help that
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professionals provide. Moreover, there is a strong consensus
about the features of effective help-giving and the qualities of
effective help-givers. To test the validity of these conclusions,
we will examine a particular form of professional-parent
relationship about which much is known, namely, the relationship
between doctor and patient. Doctor / patient relationships There is
good evidence that the quality of doctors’ interviewing skills in
medical consultations influences patient satisfaction and
compliance as well as actual health outcomes (Di Blasi, Harkness,
Ernst, Georgiou and Kleijnen, 2001; Nobile and Drotar, 2003;
Stewart, Brown, Boon, Galajda, Meredith and Sangster, 1999;
Stewart, Brown and Weston, 1989). For instance, on the basis of a
systematic review of the research, Di Blasi, Harkness, Ernst,
Georgiou and Kleijnen (2001) concluded physicians who adopt a warm,
friendly, and reassuring manner are more effective than those who
keep consultations formal and do not offer reassurance. The
importance of doctors’ communication skills is highlighted in a
review by Stewart, Brown, Boon, Galajda, Meredith and Sangster
(1999). They found that complaints and malpractice actions about
doctors are usually due to communication problems rather than
issues of technical competency. They also found that effective
communication promotes patient adherence to recommended treatment
plans, and have a generally positive effect on actual patient
health outcomes such as pain, recovery from symptom, anxiety,
functional status, and physiologic measures of blood pressure and
blood glucose. Another review of parent-provider communication
(Nobile and Drotar, 2003) found that effective parent-provider
communication is associated with parental satisfaction with care,
adherence to treatment recommendations, and enhanced discussion of
psychosocial concerns. Moreover, interventions designed to improve
parent-provider communication resulted in more discussion of
psychosocial concerns, better recall of information from the visit,
and improved parent-provider communication. Although doctors who
communicate better generally get better results, there is evidence
that some people may value or benefit more than others from such
patient-centred approaches. In a large-scale study, Little,
Everitt, Williamson, Warner, Moore, Gould, Ferrier and Payne (2001)
explored patient's preferences for patient-centred consultation in
general practice. They found that, from the patients' perspective,
there are at least three important and distinct domains of
patient-centredness: communication, partnership, and health
promotion. While most patients wanted such an approach rather more
than they wanted a prescription or an examination, those who were
vulnerable - either psychosocially or because they are feeling
particularly unwell – expressed a stronger preference for
patient-centred care. The principles of family-centred care
(American Academy of Pediatrics Committee on Hospital Care, 2003;
Shelton and Stepenek, 1994) and patient-centred care (Little,
Everitt, Williamson, Warner, Moore, Gould, Ferrier and Payne, 2001;
Stewart, 2001) in medical settings match those of family-centred
practice that were identified earlier. Family-centered care is
based upon collaboration among patients, families, physicians,
nurses, and other professionals for the planning, delivery, and
evaluation of health care as well as in the education of health
care professionals (American Academy of Pediatrics Committee on
Hospital Care, 2003). These collaborative relationships are guided
by core principles, including:
• respecting each child and his or her family • honouring
racial, ethnic, cultural, and socioeconomic diversity • recognizing
and building on the strengths of each child and family
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• supporting and facilitating choice for the child and family •
collaborating with families at all levels of health care These
principles have been adopted not simply because it is felt that
doctors ought to respect and collaborate with patients, but because
health care based upon such principles has been shown to be more
beneficial to patients. Thus, American Academy of Pediatrics
Committee on Hospital Care (2003) concludes that there is evidence
that family-centered care can
• improve patient and family outcomes, • increase patient and
family satisfaction, • build on child and family strengths, •
increase professional satisfaction, • decrease health care costs,
and • lead to more effective use of health care resources. Given
the importance of the doctor-patient relationship, what do we know
about the qualities of effective doctor-parent communication?
According to Stewart, Brown, Boon, Galajda, Meredith and Sangster
(1999), the evidence indicates that the key features of effective
communication involve
• providing the patient with clear information, • reaching
agreement on goals and expectations, • encouraging the patient to
play an active role, and • providing positive affect, empathy and
support. According to Brown, Stewart and Tessier (1995), the main
domains of patient-centred care are
• exploring the experience of disease and illness - patients'
ideas about the problem, feelings, expectations for the visit, and
effects on function
• understanding the whole person - personal and developmental
issues (for example, feeling emotionally understood) and the
context (the family and how life has been affected)
• finding common ground (partnership) - problems, priorities,
goals of treatment, and roles of doctor and patient
• focusing on health promotion - health enhancement, risk
reduction, early detection of disease
• enhancing the doctor-patient relationship - sharing power, the
caring and healing relationship
Once again, the evidence indicates that how medical
practitioners relate to patients can have a significant impact on
the extent to which patients implement recommended treatment plans,
as well as on actual health outcomes. The key qualities of
effective doctor-patient relationships include some we have seen
before in other relationships, such as listening to the other
person’s experience and ideas, providing empathic support, and
seeking to work as partners. Next, we consider the evidence
regarding another subset of professional-parent relationships that
has been well studied, that between psychotherapists and
clients.
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Relationships in psychotherapy As with doctor / patient
relationships, the evidence clearly indicates that the quality of
relationships between psychotherapists and their clients is
important for outcomes (Orlinsky and Howard, 1986; Wampold, 2001).
In a review of studies of outcomes in psychotherapy, Orlinsky and
Howard (1986) found that factors related to the quality of the
emotional connection between the patient and the therapist was far
more important than the theoretical orientation of the therapist.
This conclusion is supported by analyses of the efficacy literature
conducted by the Institute for the Study of Therapeutic Change
(http://www.talkingcure.com/whatworks.htm) which found that the
client’s relationship with the therapist typically accounted for
around 30% of the effectiveness of particular therapies, whereas
the therapeutic model and/or technique used only accounted for
around 15%. How does the therapist-client relationship create
change? Cozolino (2002) has approached this question by examining
the neurobiology of psychotherapeutic change. He suggests that all
forms of psychotherapy are successful to the extent to which they
enhance change in relevant neural circuits. In his account, the
brain is an organ that is continually built and re-built by one’s
experiences, and psychotherapy is one of the social contexts
through which people’s brains can be changed. Specifically, there
is evidence that empathic connectedness and emotional nurturance
from an attuned therapist can trigger biochemical processes that
increase brain plasticity, ie. relearning. Drawing on the evidence
from neuroscience and psychotherapy, Cozolino concludes that the
important factors in effective psychotherapy are an emotionally
safe and empathic relationship, the activation of moderate anxiety
and stress, and the use of narrative:
• A safe and empathic relationship establishes an emotional and
neurobiological context conducive to the work of neural
reorganisation. It serves as a buffer and scaffolding within which
a client can better tolerate the stress required for neural
reorganisation.
• Emotion and stress are important in the process of change
because they stimulate the biochemical environment for neural
plasticity. Optimal levels of arousal and stress result in
increased production of neurotransmitters and neural growth
hormones that enhance long-term potentiation, learning, and
cortical reorganisation.
• Language is important because it allows us to create
autobiographical narrative that bridge processing from various
neural networks into a cohesive and integrated story of the self.
Narratives allow us to combine - in conscious memory - our
knowledge, sensations, feelings, and behaviours supporting
underlying neural network integration.
The findings regarding therapist / client relationships add to
the body of evidence that relationships matter, and that how
helpers relate to help-seekers makes a difference to the outcomes
achieved. The evidence also suggests that these effects can be seen
at a neurological as well as a behavioural level, and that key
factors contributing to change include establishing a relationship
based on empathy, and the use of positive stress and of narratives.
We turn to the next level in the system of services and consider
the relationships between managers or supervisors and their staff.
Again, the key questions to be considered are whether the nature
and quality of these relationships affect the nature and quality of
the services that the professionals in turn provide to parents and
families, and what we know about the qualities of effective
management and supervision.
http://www.talkingcure.com/whatworks.htm
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14
Manager / supervisor and staff relationships The organisational
climates that managers and supervisors establish are a significant
predictor of service outcomes and service quality. Glisson and
Hemmelgarn (1998) describe how organisational climate might affect
the work of those providing services to children and families who
are at risk of a variety of physical and psychosocial problems:
‘Because the effectiveness of these services depends heavily on
the relationships formed between service providers and the people
who receive the services, the attitudes of the service providers
play an especially important role in the outcomes of services.
Successful outcomes require caseworkers to be responsive to
unexpected problems and individualized needs, tenacious in
navigating the complex bureaucratic maze of state and federal
regulations, and able to form personal relationships that win the
trust and confidence of a variety of children and families. Also,
caseworkers must perform their jobs in highly stressful situations
that can involve, for example, angry family members or seriously
emotionally disturbed children. Therefore, the levels of conflict,
role clarity, job satisfaction, cooperation, personalization, and
other variables that characterize the shared attitudes and climate
of their work environments should be powerful determinants of how
caseworkers respond to unexpected problems, the tenacity with which
difficult problems are solved, and the affective tone of their
work-related interactions with children and families.’
In a study exploring this hypothetical causal chain, Glisson and
Hemmelgarn (1998) found that improvements in psychosocial
functioning are significantly greater for children served by
workers from offices with more positive climates. In the early
childhood field, an example of the importance of management style
and organisational climate is given by Pawl (1994/95). Based on her
experience as a mental health consultant to childcare centres, she
found that, in those programs with the poorest relationships
between providers and children, there was an unclear flow of
authority, while at the same time there were markedly authoritarian
methods of doing business with one another. Relationships between
staff and director, and between staff and staff were marked by a
great deal of hostility, disrespect and insensitivity. This had
flow-on effects: those providers who were treated the worst,
treated the children the worst. The same story emerges when we look
at the relationship between supervisors and supervisees, and
between trainers and trainees. For instance, in a discussion of
supervision, Pawl (1994/95) states that ‘How one is with someone,
how one treats someone -- has an important impact which should not
be overlooked.’ She suggests that supervisors need to understand
this kind of influence if the supervisory relationship is to become
truly supportive of the practitioner’s work with families.
Supervisory relationships that lack the key qualities of respect,
mutuality and safety may teach some techniques and skills, but will
not reach the heart of what practitioners need to learn and
experience to be most effective with their families. This is also
true of trainers and trainees. On the basis of their experience in
running an early intervention training program, Mikus, Benn and
Weatherston (1994/95) concluded that certain principles of
family-centred practice were essential not only for effective work
with families but also for the successful implementation of the
early intervention training process itself. That is, trainers
needed to incorporate principles of family-centred service into
their interactions with their trainees. The training would have
been less successful without a sensitive and skilful application of
family-centred principles and practices by the trainers. When the
training facilitator follows and models family-centred practices
throughout a training experience, participants are able to
experience first-hand the positive regard and sense of
meaningfulness which results from being treated respectfully and
valued as collaborative
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15
partners. In this way, participants are empowered to use this
approach with the families with whom they work. Another finding was
that this was true regardless of the composition of the particular
training group. That is, experienced as well as novice
professionals were able to benefit from this approach, as well as
practitioners from a range of disciplines and settings. These same
principles inform the family partnership training developed by
Hilton Davis and colleagues in the UK (Davis, Day and Bidmead,
2002). In this model, the trainers seek to embody the principles
they teach – that is, they relate to the trainees in the way that
they want them to relate to the families they work with. So far, we
have considered relationships between parents / caregivers and
children, between various professional helpers and families /
clients, and between managers / supervisors and staff members. We
will now take a wider social perspective, and examine relationships
between professional agencies / networks and communities, and
between government and professional agencies / networks.
Relationships between services / service systems and communities
Many service agencies and service networks seek to work with the
communities they serve. There is a growing consensus that the most
effective way for service systems to work with communities is to
use a family-centred community-building approach (Adams and Nelson,
1995; Doherty and Carroll, 2002; Mulroy, Nelson and Gour, 2005).
What are the grounds for using such an approach? Based on synthesis
of key evidence-based and practice-based analyses (Adams and
Nelson, 1995; Botes and van Rensburg, 2000; Edgar, 2001; Kretzmann
and McKnight, 1993; Llewellyn-Jones, 2001; Maton, Dodgen,
Leadbeater, Sandler, Schellenbach and Solarz, 2004; Schorr, 1997;
Wandersman and Florin, 2003; Weissbourd, 2000), the rationale for
adopting such an approach is as follows: •
•
•
•
•
Better outcomes can only be achieved through whole-of-government
and whole-of community approaches
The traditional problem-based and deficiency-based approach to
working with families and communities is not effective enough
There are alternative asset-based and strength-based approaches
that are more effective
The service system needs to become more promptly and truly
responsive to the needs of families and communities
To achieve these changes, the nature of the relationship between
governments and communities needs to reconceptualised
Based on the same sources, the key features of community-centred
practice are as follows: • Service delivery is based on a
partnership between professional services and
communities
• Decision-making is shared between communities and professional
services
• Services are tailored to meet the needs and priorities of
particular communities
• Professionals work with communities to identify and build on
community assets and strengths
• A capacity-building and empowerment approach is used to help
communities develop solutions to their own problems
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16
• Local resources are mobilised to meet local needs, and new
resources developed as required
• Services are available to all children and families as the
need arises
• Professionals collaborate to provide an integrated and
holistic system of child and family support services
It is apparent that these features of effective
community-building are very similar to the features of effective
family-centred practice - there is the same emphasis on basing
services on local needs, on building partnerships, and on strength
building. Again, this approach is being adopted not simply because
it is more respectful or democratic, but because it is more
effective, that is, it results in more cohesive communities and in
services that are more responsive to community needs. Finally, we
turn to a consideration of the relationships between governments
(whether local, state or federal) and communities. Government /
community relationships Perhaps the most challenging relationships
to analyse are those between governments and the communities they
represent. Of all the relationships so far considered, that between
the elected representatives of the people and the people themselves
is the least susceptible to controlled trials and the other
apparatus of academic proof. Nevertheless, there are some
interesting synchronicities between government / community
relationships and the other forms of relationships that we have
been examining. Just as there has been a push for service systems
to work more collaboratively with communities, there has also been
calls for a reinvention of human services and of the way that
governments do business (Adams and Nelson, 1995; Considine, 2005;
Edgar, 2001; OECD, 2001; Schorr, 1997). For instance, Edgar (2001)
argues that
‘The essence of postmodern society is complexity and diversity,
where no lumbering, centrally controlled system can cope.
Adaptability is the name of the game. The new global service –
communication economy, now being called the knowledge economy, is
the one in which neither centralised government services nor
centralised corporate leadership can manage the diverse and
ever-changing needs of work, family and community life. One size
will no longer fit all. Government will have to allow for
tailor-made solutions to widely different regional circumstances.’
(p. 2)
This means reconceptualising the role of government as one of
‘facilitating community-building through a range of genuine
partnerships with business and community organisations, not as
providing (or even purchasing) services top-down’ (Edgar, 2001, p.
107). What this would involve is a combination of top-down
guidelines and locally autonomous decision-making about how these
guidelines would be implemented. Edgar calls for governments to
adopt a new model of resourcing communities. A key feature of this
approach is local family and community participation in defining
service needs and programs of action, based on existing resources
and community strengths. Dokecki and Heflinger (1989) note that the
implementation of government policies is usually tackled from the
top down (which they call forward mapping) and that this approach
is not very effective. They recommend an alternative approach,
dubbed backward mapping by Elmore (1979-1980), which begins by
identifying what a policy is supposed to achieve at the ground
level, at what Lipsky (1980) calls the street level:
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17
‘Having carefully specified these street-level policy outcomes,
the implementation analytic task is to map backward from the
loosely coupled organizations involved in the policy system to
determine what must be in place or occur at successively higher
levels of the system. lt is as if we turn the policy telescope
around and look through the lens at the other end. The resulting
vista is unusual, but important.’ (p. 61)
Dokecki and Heflinger (1989) see backward mapping and forward
mapping as complementary, not competing, approaches:
‘In all our top-down concerns with the machinations of the
policy and service delivery systems, however, our focus on what is
really at stake [in implementing any new policy or law] must be
kept intact: strengthening families – because they are the most
crucial element in the social ecology of young children with
handicapping conditions.’ (p. 81)
Does this kind of approach achieve better results?
Llewellyn-Jones (2001) has reviewed the literature on community
participation in health promotion, concluding that there is strong
evidence that involvement of community members in health promotion
activities creates more effective outcomes. To achieve such
results, health professionals need to accept the agenda set by the
communities, be willing to share their sources of power, knowledge
and skills, and to take on roles that facilitate and mobilise
community action. Schorr (1997) is another who has argued that
community participation is vital for effective service delivery. On
the basis of a converging body of knowledge derived form theory,
research and practice, Schorr identifies seven attributes of highly
effective human services programs, one of which is as follows:
Successful programs deal with families as parts of
neighbourhoods and communities. Successful interventions cannot be
imposed from without, but respond to the needs identified by the
community.
In considering the relationship between governments and service
providers, or government and communities, it is worth remembering
the aphorism attributed to Tip O’Neill, long-term speaker of the US
House of Representatives, that ‘All politics is local’. That is,
governments do not have relationships with communities or service
systems – people in government have relationships with people in
communities and services. The ability of governments to work
effectively with communities and services is therefore dependent
upon the quality of the relationships involved, and these
relationships will operate according to the same dynamics as all
the other forms of relationship we have been considering. The
implication is that the relationships that governments have with
communities and with service systems will be less effective when
politicians and bureaucrats fail to tune in to the experiences of
communities and services, do not adopt a true partnership approach
to policy development and service provision, and have a high
turnover rate of frontline staff.
~ ~ ~ ~ ~ Having looked at the evidence that relationships
matter, we now turn to the evidence regarding the qualities of
effective relationships to see if there are common key qualities
across all levels of relationships.
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COMMON FEATURES OF EFFECTIVE RELATIONSHIPS This paper proposes
that there are features that are common to all the different
relationships we have examined. These common features are the
following:
• attunement / engagement,
• contingent responding,
• emotional communication,
• understanding one’s own feelings,
• managing communication breakdowns,
• empowerment and strength-building,
• moderate stress / challenges, and
• building coherent narratives. These features appear again and
again in the evidence we have been considering regarding the
qualities of effective relationships of different types. Each of
these will be examined in turn. Attunement / engagement The
starting point for all effective relationships is tuning to the
other person’s world, understanding their perspective and
experience, and successfully communicating that understanding to
them. This is what true engagement is based upon. Two key skills
needed for effective attunement and engagement are observation and
listening. Observation involves paying close attention to the other
person or people, noting body language and behaviour and what they
say and do and what this tells you about their states of mind and
body. For those trained to act and intervene, learning to observe
can be challenging - as Pawl and St. John (1998) put it, the
challenge is ‘Don’t just do something, stand there and pay
attention’. The other key to effective attunement and engagement is
listening. Listening involves ‘the ability of helpers to capture
and understand the messages clients communicate, whether these
messages are transmitted verbally or nonverbally, clearly or
vaguely’ (Egan, 1994, p. 90). This involves more than the listener
being able to repeat what the person is saying:
‘Complete listening involves four things: first, observing and
reading the client’s nonverbal behaviour – posture, facial
expressions, movement, tone of voice, and the like. Second,
listening to and understanding the client’s verbal messages. Third,
listening to the context; that is, to the whole person in the
context of the social settings of his or her life. Fourth,
listening to the sour notes; that is, things the client says that
may have to be challenged.’ (p. 94)
Like the skill of observation, this is a complex and demanding
task that challenges professionals who have been trained to find
specific solutions to narrowly-defined problems rather than to
support people in finding their own ways of dealing with the
situations in which they find themselves.
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19
Contingent responding A second key feature of effective
relationships is contingent responding, that is, when those
involved in the relationship respond promptly and appropriately to
each others’ signals, communications and changing states. This can
be done nonverbally (through facial expressions and body language)
or through direct verbal communication. In the case of young
children, contingent responding takes the form of caregivers
recognising the signals the children are sending, making sense of
them in their own minds, and then communicating to the children in
such a manner that helps the children understand their own mental
states and those of the caregiver (Siegel, 2001).
The key factor to babies flourishing is responsiveness: ‘babies
need not too much, not too little, but just the right amount of
responsiveness - not the kind that jumps anxiously to meet their
every need, nor the kind that ignores them too long, but the kind
of relaxed responsiveness that confident parents tend to have’
(Gerhardt, 2004, pp. 196-197). The best responsiveness for babies
is the ‘contingent’ kind: ‘This means that the parent needs to
respond to the actual needs of their particular baby, not to their
own idea of what the baby might need.’ (Gerhardt, 2004, p. 197)
Contingent responsiveness is also important in relationships
between adults:
‘If you think about your own experience as an adult, you may
become aware that you too need contingent responses. General
‘niceness’, such as people being ‘kind’ when you're upset in some
way, can be quite useless; it washes over you. In fact, very often
such niceness is an attempt to drown your feelings and make them go
away, just as much as a punitive response does. What works much
better is to feel other people willing to get on your wavelength -
understanding the specific way that you are feeling, helping you to
express it, and thinking about solutions with you.’ (Gerhardt,
2004, p. 197)
Emotional communication A third characteristic of effective
relationships is that those involved acknowledge each other’s
emotions, both the positive joyful ones as well as the negative
uncomfortable ones. It is through the acknowledgment and sharing of
these experiences that emotional intelligence / emotional literacy
develops (Gerhardt, 2004; Goleman, 1995; Gottman, 1998; Siegel,
2001). The development of emotional intelligence and regulation is,
in turn, a prerequisite for the subsequent development of positive
mental and physical health and well-being:
‘There are many well-trodden pathways to misery. People may
choose to eat too much or too little, drink too much alcohol, react
to other people without thinking, fail to have empathy for others,
fall ill, make unreasonable emotional demands, become depressed,
attack others physically, and so on, largely because their capacity
to manage their own feelings has been impaired by their poorly
developed emotional systems.’ (Gerhardt, 2004, p. 87)
According to the National Scientific Council on the Developing
Child (2005), the core features of emotional intelligence or
emotional literacy include the ability to
• identify and understand one's own feelings,
• accurately read and comprehend emotional states in others,
• manage strong emotions and their expression in a constructive
manner,
• regulate one's own behaviour,
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20
• develop empathy for others, and
• establish and sustain relationships To promote these skills in
young children, parents and caregivers need to become ‘emotion
coaches’ (Gerhardt, 2004; Gottman, 1998; Greenberg, 2002). This
involves learning how to:
• be aware of a child's emotions
• recognize emotional expression as an opportunity for intimacy
and teaching
• listen empathetically and validate a child's feelings
• label emotions in words a child can understand
• help a child come up with an appropriate way to solve a
problem or deal with an upsetting issue or situation (Gottman,
1998)
Emotion coaching is also used in therapy with adults. In the
approach developed by Greenberg (2002),
‘…. an emotion coach helps people identify emotions,
differentiate what they feel from what others feel, tolerate
emotions, synthesise contradictory emotions, use emotions as
information, articulate feelings in words or symbols, use emotion
to facilitate thinking, develop emotion knowledge, and reflect on
emotions. These are all the tasks of emotional development. They
occur throughout childhood and later life and are helped greatly by
therapy.’ (p. xii)
Understanding one’s own feelings A fourth characteristic of
effective relationships, closely related to the previous one, is
understanding and managing one’s own emotions. A number of the
other key qualities of effective relationships depend upon this
ability. Acknowledging and managing one’s own feelings is an
important component of effective help-giving. Human service
providers need to be aware of their own emotional reactions to the
people they are working with and the situations they face. This
includes being aware of ‘the judgments, wishes, intolerances, hot
buttons, or fears that one brings or that become activated in
clinical encounters’ (Heffron, Ivins and Weston, 2005). It also
includes being aware of and appreciating that the internal worlds
of others are equally diverse and as individually unique as our
own. As Miller and Sammons (1999) point out, we cannot avoid
reacting to differences in others we meet - our first reactions are
automatic reflexes, built into our brains. What we do after our
first reaction, however, is based on our learning and choices. So,
although we cannot control our first automatic responses, we can
learn to manage our reactions so that they do not get in the way of
our work.
In relationships between parents / caregivers and children,
understanding and being able to manage one’s feelings is also
crucial. If caregivers do not have a comfortable relationship with
their own feelings, they may not be able to help children become
emotionally literate very effectively (Gerhardt, 2004). The
attitudes we learn to towards feelings are crucial:
'If they are seen as dangerous enemies, then they can only be
managed through exerting social pressure and fear. Alternatively,
if every impulse must be gratified, then relationships with others
become only a means to your own ends. But if feelings are respected
as valuable guides to the state of your own organism, as well as
that
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21
of others, then a very different culture arises in which others’
feelings matter, and you are motivated to respond.’ (Gerhardt,
2004, p.30)
Managing communication breakdowns A fifth key feature of
effective relationships is that those involved are able to
acknowledge communication breakdowns and restore positive
connections when these occur. This has been identified as important
in a number of different types of relationships, including those
between parent and child (Siegel, 2001) and between members of
professional teams (Brunelli and Schneider (2004). When attuned
communication between parent and child is disrupted, as it
inevitably will be, repair of the rupture is an important part of
re-establishing the connection (Siegel, 2001). Repair is important
in helping to teach the child that life is filled with inevitable
moments of misunderstandings and missed connections that can be
identified and connection created again. Prolonged disconnection,
especially if combined with hostility and humiliation, can have
significant negative effects on a child’s developing sense of self.
Empowerment and strength-building A sixth feature of effective
relationships of different kinds is that they are characterised by
an emphasis on each other’s strengths and competencies, rather than
on weaknesses and problems. In human services, the strength-based
approach is based on the proposition that ‘the strengths and
resources of people and their environments, rather than their
problems and pathologies, should be the central focus of the
helping process’ (Chapin, 1995, p. 507).). The aim or outcome of
this approach is that ‘family members will increase their belief in
their ability to learn and make changes in their family life, their
ability to think and act critically with regard to life situations,
and their power over negative circumstances' (Erickson and
Kurz-Riemer, 1999, p. 118). Adopting a strength-based approach is a
common recommendation for a wide range of relationships, including
working with children (Pollard and Rosenberg, 2002), families
(Bernard, 2006; Silberberg, 2001) and communities (Perkins, Crim,
Silberman and Brown, 2004; Schorr, 1997). It also recommended in
diverse areas such as early childhood intervention (Erickson and
Kurz-Riemer, 1999), child welfare (Berg, 1994; McCashen, 2004;
Scott and O'Neil, 1996), social work (Petr, 2004; Saleebey, 2006),
and mental health (DeJong and Miller, 1995). A major reason for
adopting a strength-based approach in relationships is that better
outcomes are achieved. Thus, according to Solarz, Leadbeater,
Sandler, Maton, Schellenbach and Dodgen (2004),
‘Strengths-based approaches work. They are effective strategies
for promoting healthy individuals, families and communities and
reducing major social problems.’ (p. 344)
The six characteristics of effective relationships that have
been mentioned so far are relatively obvious. The last two may be
less so. Moderate stress / challenges Effective relationships are
characterised by moderate stress and challenges. There are a number
of different angles to the stress story.
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Moderate stress as a stimulus to development. On the basis of
research on individual differences in sensitivity to risk, Rutter
(2000) suggests that the qualities that provide resistance to
stress-adversity may be acquired through appropriate experiences.
Such experiences include successful coping with life’s challenges
(attempts to shield children completely from stress may be damaging
as well as futile); taking responsibility and exercising autonomy
and decision taking; and having secure, harmonious, personal
relationships. According to the National Scientific Council on the
Developing Child (2005),
‘Stressful events can be harmful, tolerable, or beneficial,
depending on how much of a bodily stress response they provoke and
how long the response lasts. These, in turn, depend on whether the
stressful experience is controllable, how often and for how long
the body’s stress system has been activated in the past, and
whether the affected child has safe and dependable relationships to
turn to for support. Thus, the extent to which stressful events
have lasting adverse effects is determined more by the individual’s
response to the stress, based in part on past experiences and the
availability of a supportive adult, than by the nature of the
stressor itself.’
The National Scientific Council on the Developing Child (2005)
identifies three types of stress:
• Toxic stress refers to strong, frequent or prolonged
activation of the body’s stress management system. Stressful events
that are chronic, uncontrollable, and/or experienced without the
child having access to support from caring adults tend to provoke
these types of toxic stress responses. Studies indicate that such
stress responses can have an adverse impact on brain
architecture.
• Tolerable stress refers to stress responses that could affect
brain architecture but
generally occur for briefer periods that allow time for the
brain to recover and thereby reverse potentially harmful effects.
In addition to their relative brevity, one of the critical
ingredients that make stressful events tolerable rather than toxic
is the presence of supportive adults who create safe environments
that help children learn to cope with and recover from major
adverse experiences, such as the death or serious illness of a
loved one, a frightening accident, or parental separation or
divorce.
• Positive stress refers to moderate, short-lived stress
responses, such as brief
increases in heart rate or mild changes in the body’s stress
hormone levels. This kind of stress is a normal part of life, and
learning to adjust to it is an essential feature of healthy
development. Adverse events that provoke positive stress responses
tend to be those that a child can learn to control and manage well
with the support of caring adults, and which occur against the
backdrop of generally safe, warm, and positive relationships. Such
experiences are an important part of the normal developmental
process.
Key feature of good parenting. Moderate stress stimulates
neurological development and integration in the young child (Stien
and Kendall, 2004). Whereas one-year-olds receive mostly positive
responses from parents, toddlers receive more prohibitions. This
demand for impulse control creates mild stress, causing an increase
in the delivery of neurochemicals associated with the stress
response to the prefrontal cortex. This stimulates the formation of
the descending pathways from the prefrontal cortex to the lower
regions of the brain. These descending pathways eventually allow
the prefrontal cortex to override the desires that are generated in
the lower centres of the brain. Because the ascending tracts mature
first,
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23
unbridled expressions of emotions (such as temper tantrums) are
common among toddlers aged 18 to 36 months. This cannot end until
an efficient inhibitory system has been laid down. Responding
positively to adversity. There is evidence that some people emerge
stronger from adverse experiences, with capacities that may not
have emerged otherwise. There are even arguments that resilience
does not develop in spite of adversity, but because of it (Bonanno,
2004; Linley and Joseph, 2005; Walsh, 1998). For instance, Bonanno
(2004) argues that resilience in adults has often been
underestimated and misunderstood, being viewed either as a
pathological state or as something seen only in rare and
exceptionally healthy individuals. He reviews evidence that
resilience in the face of loss or potential trauma is more common
than often believed, and that there are multiple and sometimes
unexpected pathways to resilience. Similarly, there is evidence
that parents of children with disabilities can transcend the
distress and disruption involved, and end up stronger than before
(Flaherty and Glidden, 2000; King, Zwaigenbaum, King, Baxter,
Rosenbaum and Bates, 2006). Challenging in therapy and helping. As
has been seen already, effective helpers and therapists know how to
challenge those they work with in ways that creates moderate stress
and promotes positive change. Building coherent narratives The last
feature of effective relationships to be considered is the building
of coherent narratives, that is, telling stories that help people
make sense of their lives. This process is important for young
children, but also for adults. Stories are the way we make sense of
the events and our lives - both the things that happen to us and
the internal experiences that create the rich texture of each
individual is unique, subjective sense of life (Siegel and
Hartzell, 2003). Such stories are important for young children’s
development – the connection of the past, present, and future is
one of the central processes of the mind in the creation of the
autobiographical form of self-awareness (Siegel, 2001). Adults can
teach children about the world of the self and of others by joining
with them in the co-construction of stories about life events.
These stories focus on activities as well as the mental life of the
characters, and thereby give children the tools they need to make
sense of the internal and external worlds in which we all live. The
way adults make sense of the world has a profound effect on their
functioning, including their ability to parent:
‘A profound finding from attachment research is that the most
robust predictor of a child's attachment to parents is the way in
which the parents narrate their own recollections of their
childhood experiences. This implies that the structure of an
adult's narrative process - not merely what the adult recalls, but
how it is recalled - is the most powerful feature in predicting how
an adult will relate to a child. Studies of couples expecting their
first child can predict how each parent will relate to their
yet-to-be-born infant by examining the nature of the narratives of
their own childhoods.’ (Siegel, 1999, pp. 5-6)
However, Siegel and Hartzell (2003) suggest that parents are not
necessarily bound by their early attachment experiences, but can
reconstrue them in ways that gives them a different view of
themselves and thereby enables them to be relate to their children
differently. In other words, we retain the capacity to retell our
stories in ways that enable us to be function more effectively.
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~ ~ ~ ~ ~ These eight characteristics of relationships have been
identified because they appear repeatedly in research studies and
analyses of widely differing forms of relationships. One of the
possible reasons why this occurs is that all forms of relationship
have a common neurobiological base. We will now look at what we
know about the neurobiology of interpersonal relationships. THE
NEUROBIOLOGY OF INTERPERSONAL RELATIONSHIPS We are steadily
building a picture of the neurological basis for some of these core
features of effective relationships (Cozolino, 2002; Gerhardt,
2004; Schore, 1994, 2003a, 2003b; Siegel, 1999, 2001) and of what
Siegel (1999) has called the neurobiology of interpersonal
development. Key aspects of this neurobiological perspective are
that
• children develop in the context of interpersonal relationships
– early neurobiological development is determined by the quality of
their attachment experiences
• later development continues to be determined by the nature of
relationships – the brain can be ‘reprogrammed’ through positive
relationships
• professional services (such as psychotherapy) can also
‘reprogram’ the brain These programming and reprogramming processes
involves two complementary aspects of brain functioning: hormonal
and neurochemical reactions and mirror neurons. Hormonal /
neurochemical reactions are involved in all aspects of brain
development and functioning. When we are babies, the positive looks
and smiles we see in our parents trigger the release of pleasurable
neurochemicals (opiates) that actually help the brain to grow.
These neurochemical responses, in turn, trigger an enormous
increase in glucose metabolism during the first two years of life
(Schore, 1994). The exact sequence is as follows (Gerhardt,
2004):
• When the baby looks at the mother (or father), he/she reads
their dilated pupils as indicating that their sympathetic nervous
system is pleasurably aroused
• In response, the baby’s own nervous system gets pleasurably
aroused and his/her heart rate goes up
• These processes trigger off a biochemical response: a pleasure
neuropeptide (called beta-endorphin) is released into circulation,
specifically into the orbitofrontal region of the brain
• Natural opioids like beta-endorphin help neurons grow, by
regulating glucose and insulin, as well as making you feel good
• At the same time, another neurotransmitter called dopamine is
released from the brainstem and also makes its way to the
prefrontal cortex
• This also enhances the uptake of glucose there, helping new
tissue to grow These naturally-occurring opioids are just some of
the many neurochemicals that play an important role in brain
functioning and development. As Johnson (2004) points out, one
could get arrested for ingesting these same drugs in synthetic
form. Indeed, artificial drugs are addictive precisely because they
mimic the naturally occurring pleasure drugs in the brain.
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Relationships can also protect young children from the damaging
effect of toxic hormones and neurochemicals. For instance, the
relationships children have with their caregivers help regulate
stress hormone production during the early years of life.
‘Those who experience the benefits of secure relationships have
a more controlled stress hormone reaction when they are upset or
frightened. This means that they are able to explore the world,
meet challenges, and be frightened at times without sustaining the
adverse neurological impacts of chronically elevated levels of
hormones such as cortisol that increase reactivity of selected
brain systems to stress and threat. In contrast, children whose
relationships are insecure or disorganized demonstrate higher
stress hormone levels when they are even mildly frightened. This
results in an increased incidence of elevated cortisol levels which
may alter the development of brain circuits in ways that make some
children less capable of coping effectively with stress as they
grow up.’ (National Scientific Council on the Developing Child,
2005)
The presence of sensitive and responsive caregivers – in the
home or in early care and education settings - can prevent
elevations in cortisol among toddlers, even in children who are
temperamentally fearful or anxious. The other neurological basis of
some of the core features of effective relationships are what are
known as mirror neurons. Mirror neurons represent the neural basis
of a mechanism that creates a direct link between the sender of a
message and its receiver. Mirror neurons are found in various parts
of the brain and function to link motor action to perception. A
particular mirror neuron will fire if you watch someone else doing
something intentionally, and will also fire if you do the same
action yourself. These neurons do not merely fire in response to
any action seen in another person: the behaviour must have an
intention behind it. Thanks to this mechanism, actions done by
other individuals become messages that are understood by an
observer without any cognitive mediation (Gallese, 2003; Rizzolatti
and Craighero, 2004). Originally identified in monkeys, there is
now rapidly accumulating evidence of their existence in humans
(Stefan, Cohen, Duque, Mazzocchio, Celnik, Sawaki, Ungerleider and
Classen, 2005), and of the important role they may have played in
the evolution of human brains and language (Ramachandran, 2000;
Stamenov and Gallese, 2002). Siegel and Hartzell (2003) suggest
that mirror neurons are central to creating resonance between the
minds of parents and infants. Mirror neurons not only enable the
brain to detect the intention of another person, but also link the
perception of emotional expressions to the creation of those states
inside the observer. In this way, when we perceive another's
emotions, automatically, unconsciously, that state is created
inside us. There is some evidence that a dysfunctional mirror
neuron system in high-functioning individuals with autism spectrum
disorder might underlie their deficits in theory of mind and
empathy (Dapretto, Davies, Pfeifer, Scott, Sigman, Bookheimer and
Iacoboni, 2006; Oberman, Hubbard, McCleery, Altschuler,
Ramachandran and Pineda, 2005). The existence of mirror neurons may
be one of the reasons why true intentions and feelings cannot be
faked. Without knowing it, we process a host of non-verbal signals
from others – facial expressions, body language – that convey
information about their true feelings and intentions. The human
face has 90 different muscles which in various combinations can
form as many as 10,000 expressions. About half of these can provide
information about our intentions. Using this information, children
are able to see when there is a gap between what parents say and
what they really mean or feel.
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This may lie behind the observation made by Dunst and Trivette
(1996) that key aspects of help-giving cannot be faked. As noted
earlier, they propose that there are three aspects of effective
helping, all three of which need to be present for helpgiving to be
truly effective: technical knowledge and skills, help-giver
behaviours and attributions, and participatory involvement. The
second and third components provide value-added benefits, but
cannot be faked:
‘Research indicates that help receivers are especially able to
‘see through’ helpgivers who act as if they care but don’t, and
helpgivers that give the impression that help receivers have
meaningful choices and decisions when they do not.’ (Dunst and
Trivette, 1996, p. 337)
~ ~ ~ ~ ~
Having considered the growing evidence regarding the
neurobiological basis of relationships, we will now consider one of
the major implications of the finding that different forms of
relationship have common features: that what are known as parallel
processes operate across the spectrum of relationships. PARALLEL
PROCESSES The concept of parallel process will be familiar to those
who work in infant mental health or social work. In these fields,
it refers to the way that the relationship between a professional
and a client parallels the relationship between the client and
others in their lives, and therefore has the capacity to strengthen
or weaken such relationships. Thus, there is a flow-on effect, in
which relationships influence relationships (Johnston and Brinamen,
2005). This flow-on effect can be seen in the relationships between
early childhood professionals and parents of young children:
‘People learn how to be with others by experiencing how others
are with them. This is how one’s views and feelings (internal
models) of relationships are formed and how they may be modified.
Therefore, how parents are with their babies (warm, sensitive,
responsive, consistent, available) is as important as what they do
(feed, change, soothe, protect, teach), and how [professionals] are
with parents (respectful, attentive, consistent, available) is as
important as what they do (inform, support, guide, refer,
counsel).’ (Gowen and Nebrig, 2001, p.8)
Thus, early childhood interventionists teach parents how to
relate to their young children by how they (the interventionists)
relate to the parents, rather than by directly modeling parenting
behaviour with the child. To convey a sense of this parallel
process, Jeree Pawl (Pawl, 1994/95; Pawl and St. John, 1998) has
coined a shorthand ‘platinum’ rule to supplement the Biblical
golden rule (that you should do unto others as you would have them
do unto you). Her rule is
Do unto others as you would have others do unto others. This
notion of parallel process goes beyond understanding that the
relationship between professional and parent is important. What it
adds is that the nature of that relationship needs to be informed
by the important relationships that the other person has – the way
we are with the person needs to reflect and model the way they need
to be with others in their lives. The commonalities that we found
in all the different types of relationships suggest that parallel
processes operate across the full spectrum of relationships, not
just in the
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relationship between professionals and parents. They can be seen
as forming a cascade of parallel processes:
The way that governments relate to services
parallels the way that services relate to communities
that parallels the way that managers relate to staff
that parallels the way that staff relate to parents
that parallels the way the parents relate to children What
evidence is there that parallel processes (and the cascade of
parallel processes) operate in this way and make a significant
contribution to how we develop and function? Evidence for parallel
process and the cascade of parallel processes One source of support
for the parallel process effect is the evidence that our own
ability to parent is significantly dependent upon how we were
parented. Siegel (1999, 2001, 2003) summarises this evidence,
showing that people’s own experiences of attachment to their early
caregivers (as measured by the Adult Attachment Interview) predicts
how they parent their own children. This is an illustration of the
general point made by Sue Gerhardt (2004) and cited earlier: ‘You
need to have an experience with someone first - then you can
reproduce it.’ Some support for the broader concept of relationship
cascades comes from Urie Bronfenbrenner’s work on the impact of the
social ecology on the functioning of individuals, families and
communities. On the basis of a range of ecological studies, he
identified a number of key processes that foster the development of
human competence and character (Bronfenbrenner, 1990). Three of
these involve the nature of the relationships between caregivers
and others in their social environment: • For parents to be able to
establish and maintain patterns of progressively more complex
interaction and emotional attachment with their children, they
need at least one other adult, a third party who supports,
encourages, and expresses admiration and affection for them.
Elsewhere, Bronfenbrenner (cited by Greenleaf, 1978) put it this
way: ‘A person cannot be committed to a child unless other people
are committed to that person’s commitment to children’.
• Effective child-rearing in the family and other child settings
requires establishing patterns of effective communication and
mutual trust between the principal settings in which children and
their parents live their lives (including the home, child-care
programs